The neighborhood

This trip wouldn't have been this great without the people we met here at KCMC.  I introduced Baba Alfred and his family in a previous post.  There have also been many great residents and medical students who welcomed us to KCMC and helped us find our way around.

We've also been lucky enough to meet other medical & nursing students from all over the world, as well as a few American residents and med students we wouldn't otherwise have met.

Our house on the doctor's compound happens to be inhabited only by Americans since we've been here.  Chris, a 4th year student from Mizzou, was the only one home when we arrived and was super helpful in finding our way around, giving tips on places to get internet and how to use our Vodacom phones, and introducing us to some of the other students.  Marianna returned from a Kilimajaro climb a week into our stay, and just left for home last week after a 3 month stay.  With Chris now on his own Kili climb it's been a bit quiet around here lately.

Our roommates on our last pizza & beer outing before they left (above, left) and out in town on Marianna's last night (above, right).

We've also made friends from all over the world.  Our neighbors on this street were from Wales and Sweeden, and we spent quite a bit of time exploring with them.  The Welsh girls turned out to be excellent hostesses and cooks, planing a potluck for the international and Tanzanian students last week which was quite impressive.

Here's just part of the spread:

And a picture of all 6 of us girls:

The month wouldn't have been the same without these and so many more wonderful people we've met here.  I miss them already!

Coca-cola is everywhere

One of the most surprising things we've noticed in Tanzania is that Coca-Cola is, quite literally, everywhere.  Most signs for hotels, stores, small family businesses, restaurants, and even the Moshi post-office are Coca-Cola sponsored.  Coke even supplies tables and chairs for many local restaurants, bars, and the medical school cafeteria (below).

Even our attempts to try new things not available in the U.S., such as a delicious non-acoholic ginger beer called Stoney Tangewezie, take us back to the Coca-Cola company.  And the ubiquitious drinking water, of which we've purchased gallons during our trip, says this on the label.

"The water in this bottle originally fella s snow or rain on the top of Africa's highest mountain, Kilimanjaro.  The water filters through thousands of feet of volcanic rock and lava, it surfaces on the lower slopes of the mountain and is bottled at Shirimatunda located on the Kibo volcanic lava slope."

And then, if you read a little further:

"Trademark of the Coca-Cola company."

Seriously??  I traveled 9,000 miles over 24 hours and the only thing I can find to drink that's not made by Coca-Cola is beer!

Baba Alfred and transportation in Tanzania

We've been pleasantly surprised at how easy it is to get around Tanzania, I only really miss having a car on our long, often muddy, walk to work in the mornings.

Baba Alfred ("baba" is Swahili for dad), our self-appointed Tanzanian father and protector, is our favorite taxi driver.  He is always happy to cart us to and from town and if he is busy sends a trusted friend.  He greets all of the international students and residents with a heartfelt "hello my daughters" or "hello my sons."  He is a very safe driver, which is important when you are sharing the road with trucks, motorcycles, pedestrians, and bicycles.  This past week he invited us all to his home for dinner and to meet his family.  His daughters, nieces and nephews, and grandkids were so sweet and welcoming, we had a great time.  We were stuffed with authentic Tanzanian food by the time we left, as we were enouraged to help ourselves to seconds and even thirds.  It was delicious.

Baba Alfred, his family, and his ex-pat family from the U.S., U.K., and Sweeden.

The alternative to taxis is to take the Dala Dala.  Dala dalas are smallish minivans which are then gutted on the inside to allow room for narrower, closer seats.  There are seats for 13 (3 rows of 3 and one row of 4) plus a bench against the driver's seat that holds up to 4.  We've counted 21 people packed into the dala at once, including the driver and his copilot, who opens and closes the door and occasionally hangs out the window to recruit more passengers.  It's hard to capture the atmosphere inside a dala, but this is the best pic I've managed to date:

We generaly avoid dala dalas with the exception of the one that goes directly from KCMC to the market in Moshi, as it's a fairly low traffic road and the drivers seem pretty safe.  And the ride costs only 400 shillings, or about 25 cents.  It's an interesting system, all of the dalas are privately owned but the do have licenses and about 5 registration-type stickers on the windows.  They run pre-set routes, and the ends of the route are usually, but not always, listed somewhere among the many decorations.  It also seems to be tradition to put a slogan on the back window, usually something about Jesus or Allah.  But occasionally we find a more original one, such as "Husband is not an ATM machine" or my personal favorite, "It's easy to be me, but it's not easy to love me."  It's an interesting system and I'm glad we gave it a try a couple of times, but I must say I'm much more comfortable with Baba Alfred!

Helping Babies Breathe

Our side project while at KCMC was to do some teaching on neonatal resuscitation.  We both had just come from a month on the NICU and NRP re-certification so we felt more comfortable with this.  But we used a different curriculum designed for low-resource settings, called Helping Babies Breathe.  The program emphasizes the importance of establishing breathing in the first "golden" minute of life, and teaches important skills for assessing & assisting babies in distress.

We see a lot of children with cerebral palsy from birth asphyxia here, so there is clearly a need.  The Helping Babies breathe program has been taught at KCMC in the past, and studies have even been published in Tanzania showing the decrease in neonatal mortality as a result.  But the reality is that there aren't always enough masks available, or people who feel comfortable using them.  After many visits to the obstetrics department we were able to arrange a 1 hour teaching session with the nurses and nursing students.  A longer course would have been ideal, but we did manage to hit on the important points.  Everyone got to practice on our simulation baby, Neo Natalie, and we were able to teach good technique for bag-mask ventilation.  They seemed most excited to get the extra bag-masks we'd brought along, which I hope will get a lot of use here at KCMC.

Week 3 at KCMC

We just finished our third week at KCMC.  Like most weeks here, it had its ups and downs.  And unfortunately didn't end on the happiest note.  We're glad to have a couple more days left before we leave next week.

This week the medical students were back from their vacation, which meant a much bigger crowd on rounds, but also a few more on-the-fly teaching opportunities.  The patients continue to be very sick, and we are somewhat limited in the treatments we can offer them.  I was happy to see my favorite heart failure patient discharged at the end of the week, even though we have no cure for her she was so excited to be going back home after 3 long weeks in the hospital.  We also have quite a few cute babies admitted for antibiotics for one infection or another, and all of them are doing pretty well.

Friday was a tough day on the wards.  We have several sick patients who need things like g-tubes (semi-permanent feeding tubes inserted directly into the stomach) to prevent the recurrent aspiration pneumonias they will get due to their inability to swallow food safely.  And that just isn't available here. 

We also saw our first code on Friday, although several patients have died in the last 3 weeks this was the first one we were on hand for.  Tricia was called over by a grandmother who noticed the patient slumped over, not responsive and not breathing.  She started giving breaths with the bag-mask and called for help for almost 5 minutes before someone came to get our team from rounds.  We did about 10 minutes of CPR, with lots of chaos and less than ideal equipment, and after 1 round of epinephrine we did get a heart rate back.  Eventually she started breathing on her own too, but was not responding to pain and there is a good chance the injury to her brain from so many minutes without oxygen is just too severe.  It made us acutely aware of how great the nurses, respiratory therapists, and other members of the Children's code team really are.

We also had another baby with respiratory distress and likely congenital heart disease who wasn't looking so good this afternoon, but thankfully by the time we left she was looking better.  Her mother fainted onto Tricia while we were at bedside, probably a vasovagal episode related to the stress of having such a sick baby and not eating anything all day.

After a sad and eventful day, we had a laid back dinner at the Impala Hotel and called it a night early.

Laundry, Tanzanian style

Another quick post about daily life here in Tanzania.  Any mention of our domestic life would not be complete without mention of Mary, our "house mom" or housekeeper.  She is wonderful.  Tricia has on more than one occasion proclaimed Mary to be her favorite Tanzanian.  Mary helps with dishes and keeping the kitchen clean, and shares with Tricia the never-ending task of keeping the kitchen's ant population at bay.  She also brings new bedding - this week we got princess and Spiderman sheets!  And for an extra fee (which we gladly pay, she helps with our laundry).

Laundry in Tanzania is made more difficult by a number of factors.  We haven't seen, nor have we heard rumors of, a washing machine or dryer since we arrived in the country.  Although I don't doubt that they exist, most Tanzanians do their laundry by hand.  We've learned to hand wash things in the sink, mostly things we don't want displayed in the yard or things that can't be ironed.  Anything hung outside to dry must be ironed before wearing as mango flies love to lay their eggs in any fabric left outdoors.  And since the ambient temperature is usually somewhere between 80 and 90 degrees Farenheit and the occupants of our house have been known to climb Kilimanjaro, swim in crater lakes, and generally sweat their way around the countryside, there is almost always laundry drying in the yard and on any available makeshift clothesline in the house. Things that have been repurposed for clotheslines include the detatchable shoulder straps from our duffle bags and the multiple pane windows (below) and the phone line to a non-functioning, rotary-style land line in our house.

Laundry hanging outside (below).  Mary, likely from years of practice, is much better at laundry than we are.  She manages to do it much more quickly, and with less splashing all over the kitchen and a much fresher-smelling result.  Have I mentioned yet how much we love Mary?

The key to Tanzania

The picture above is the note left by the international program coordinator with our askari (security guard) here in the doctor's compound.   The keys open our kitchen door and bedroom door.

At the first hotel we had a similar, if not identical, key which we found charming and quaint.  But as we've traveled the country we've had matching keys in multiple safari lodges, the huts on Kilimanjaro, and the tented camp at lake Chala.  Which makes us wonder how many unique keys and locks really exist in Tanzania, and how secure the locks really are.  Thank goodness for the askari!

Thankfully, at least at the doctor's compound they forgo the carved wooden or occasionally stamped leather keychains which, although very ornate, are usually the size of my shoe and equally convenient to lug around.

Shillings and dollars

A few random thoughts on life as it relates to money here in Tanzania:

We were surprised when we arrived how many places you could use the U.S. dollar.  Even more surprising was how many places only accept U.S. dollars.  It was the preferred currency for our Tanzanian visa at the airport, our resident visa application here in Moshi, and tips at hotels & on safari.  We paid for several hotels and all of our room and board & program fees in American cash.

However, the banks, and therefore the merchants, are fairly particular about only taking "new" American money.  The preferred date fluctuates but is usually sometime after the early 2000's.  They will accept both old and new hundred-dollar bills, but not my lone 1999 bill which I will apparently be packing back home with me. 

Many restaurants and stores will also accept dollars even if the shilling is preferred, however if you know the current exchange rate (about 1600-1650 shillings per dollar, depending on the bank) you'll note that such stores are only giving a rate of about 1500 shillings per dollar.  And unlike other countries I've been where U.S. dollars are commonly used, on more than one occasion I've paid in shillings and received my change in dollars.

Which brings me to my next thought: change.  There seems to be a severe and country-wide shortage of bills in the amount of 500, 1000, 2000, and 5000 shillings.  I've lost count of how many times I've been told "you need to pay with something smaller."  Which means I'm forever running out of small bills and having to put things back or add to my purchase to total something closer to 10,000 shillings.  Coming from the good ol' U.S.A. where merchants actually buy change from banks to be able to complete transactions, this can be more than a bit exasperating.  We try to get in line in order so that if the first person pays in small bills the second person can get that change back.  It's possible that the same dozen small bills are just being passed around the international housing here at KCMC.

Also, I find it interesting that I've never seen a note larger than 10,000 shillings (approximately $6.25).  Which means a relatively small amount of money can make a rather impressive pile of shillings. Now that is a fact of life here I do enjoy.

I won't be sad to give up my hoarding of small notes and go back to my trusty debit card!  And spend that "aging" 100 dollar bill.  But I will miss the colorful money!

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Lake Chala

This weekend's adventure was to the Lake Chala luxury safari camp.  We had a wonderful time!  It's a crater lake on the Tanzania-Kenya border, about an hour from Moshi.  The lake is an amazing shade of teal blue, and the perfect temperature for swimming.  Tricia and I did discover that two American's swimming would draw the attention of at least a dozen Tanzanian adolescents, who quickly comandeered our sunny branch and I'm pretty sure were talking about the wuzungu (plural, "white travelers") from what used to be our perch.  The lake is 1-2 miles across and by report 2 miles deep.  

We did see a few people getting swimming lessons - with the steep slope of the sides this is analagous to teaching someone to swim by throwing them into the deep end of the pool.  We also saw one British gentleman announce "I'm swimming to Kenya if anyone wants to join me."  No takers, but his friends did get quite worried when he was gone for four hours and out of sight.  This morning I happened to be watching the sunrise next to him and his friends, who were still lecturing him on what a dangerous and idiotic thing he did.  The man claims he swam all the way across with no problem, and that he only accepted a ride from the rescue boat mid-way back because "it was getting dark and I didn't want anyone to worry."  

The soundtrack for our delicious dinner of mango-coconut chicken was a thunderstorm over the savannah, with heavy rain and impressive lightning.  Here's a shot I caught mostly by accident:

The fact that the inclusion of the lighting was just dumb luck has not in any way diminished my pride in the finished product.

This morning we awoke in time for a beautiful sunrise over the lake.  I made one quick hike back down to the dock for a few more pictures. 

And almost forgot to mention how lovely the "luxury tents" truly were.  And surprisingly watertight even in the rain.

Week 2 update

We've had a few days with nice clear views of Kilimanjaro, this morning I finally got out in time to take a picture of one.  The small peak on the slopes of Kili is Mwenzi, which is "only 5100 meters" high as the locals say.

It's been a good but hard week.  We lost a couple of kids on my team, one to severe malnutrition and one to cerebral malaria.  I think we've been able to contribute in a helpful way now and then, and we are definitely learning a lot.

We've been trying to set up a time to teach the labor & delivery nurses the Helping Babies Breathe curriculum using the bag & masks we brought and a simulator baby.  This has proved more difficult than we expected, as the supervisors seem willing to work with us but have yet to give us a specific time to teach.  We are really hoping to do this before we leave, as birth asphyxia is an all too common cause of morbidity and mortality here and throughout Tanzania.

This weekend we are headed to Lake Chala camp, on the shores of a crater lake about 1.5 hours away.  It should be a nice relaxing weekend and yet another beautiful, scenic place.

Outreach clinic

Today I went with one of the neurology attendings (the only child neurologist in Tanzania) to the multi-disciplinary outreach clinic outside of Moshi.  It's called CCBRT, which stands for Comprehensive Community Based Rehabilitation in Tanzania.  The program is funded by the government and an NGO, and is set up to help families with special needs kids, mostly cerebral palsy, to be able to better care for the children at home.  A parent, usually the mother, comes for a 1 week stay with her child and is taught by speech, occupational, and physical therapists helpful things for taking care of a special needs child.  The clinic also can help find & fit wheelchairs and special stationary chairs to make the children more comfortable and more able to interact with their family & environment.  The neurologist goes out every Wednesday for a check-up and to treat seizures, spasticity, or any other medical issues.  It seems like a really great place.  We saw everything from young babies with developmental delays to a school-aged child who had never seen a doctor or been evaluated for seizures.  It is truly a unique set-up, and very well-run.

Chocolate chip cookies!

So Tricia and I decided that homemade chocolate chip cookies would be just the morale boost our house of Americans needed. We haven't found anything even resembling this here, although there are a few places to get delicious cakes and a Tanzanian lady who delivers cinnamon rolls to the door occasionally.  Turns out this was slightly more difficult here, without conveniences such as electric mixers and cars to take to the grocery store.  And without measuring cups...

But turns out with a coffee mug arbitrarily defined as "one cup... in Tanzania" and a recipe I may have memorized in high school with the help of my sister, it can be done.  Our one casualty was the new bag of flour that was home to a family of flies, but thankfully our roommate had some extra.  Oh and no chocolate chips to be found, but we can be quite resourceful with the right motivation.

Success!  Just the taste of home we needed:

Hospital update

We are midway through our 2nd week at KCMC.  I think we are getting more accustomed to the new hospital, and a bit more helpful to the other residents and doctors there in the process. 

LIfe in the hospital here is very different than in Dallas.  It's making me very thankful for the resources and support staff we have at Children's.  We have seen sickle cell pain crises, lots of malaria, pneumonia, sepsis, and much more heart disease than I was expected. We even saw a case of measles.  Strep pharyngitis goes untreated more often here than in the states, so it's not uncommon to see rheumatic heart disease.  Unfortunately, there is only one hospital that sees patients who need cardiac surgery, and even if they're referred there there is no guarantee that they will be a candidate for the trip to India for the surgery.  We have several medications to help with symptoms but very little we can do to fix the underlying problems. It can be very sad.

Another big struggles is not being able to communicate with the patients.  Back home I can talk to 99.9% of my patients in either English or Spanish, but here I feel very dependent on others due to my lack of Swahili knowledge.  It also makes it difficult to win the trust of the children or make them feel at ease, so even non language-dependent things like physical exams can be more challenging.

The payment system here is also very different.  There are very few people who have either government or private insurance, so the majority of our patients are self-pay.  Which means that before any test can be done the child's parents have to pay for it and bring a receipt.  I'd imagine this is a significant financial burden for many families, and may be one of the reasons some families wait so long to seek medical care.

We are learning a lot, and trying to be as helpful as we can.  Thanks for reading, and for your prayers & support!

Pole pole on the "Coca-Cola" trail

Hello all!

We just got back from a 2 day "trek" in the foothills of Kilimanjaro.  It was incredible, and made me want to sign up for a summit trek.  It'll have to wait until next trip though, as we won't have the time (or cash!) to do it while we're here. 

We hiked the first 1.5 days of the Marangu route, which our guide informed us was "nicknamed the Coca-Cola trail."  Already winded from the altitude, I asked (hoping against hope it was because we were about to discover a trail-side stand selling cold Diet Coke) "and why is that?"

"Because it's the easiest one."

Apparently there is another route which is nicknamed "the whiskey route" because it is very steep and requires some mountaineering skills as well.  Needless to say I'll be avoiding that one!

It was raining when we left Moshi, but we were pleasantly surprised that it didn't rain on us at all while we were hiking.  We started in a lush rainforest:

After 3-4 hours of hiking "pole pole" which is Swahili for "slowly, slowly" and the motto of the Kili guides, we reached the Mandara huts at 2700 meters above sea level, or 9,000 feet.  The air is thin up there but it is beautiful.  And our hut was pretty cute, although small.

We had a beautiful sunset, from a vantage point I'm used to seeing only from the window of a plane.  And a nearly-full moon at night made for a surreal landscape.

 

To our surprise, we awoke this morning to sunshine.  The clouds came rolling in shortly thereafter, but as we hiked up the mountain another couple hours we did get to see Mwenzi peak, the small peak on the slopes of Kilimanjaro.

It was a great hike, although we were glad to make it back to Moshi and a warm shower.  We were very impressed with our guides and our cook.  Somehow they managed to make chicken curry and green beans and cucumber soup for dinner, while when Tricia and I have been left to fend for ourselves in the house it's peanut-butter sandwiches or spaghetti.  

I need to write another post about the work in the hospital.  It continues to be hard in many ways, both to get used to the Tanzanian system and to see such sick children.  But I'm hopeful that we'll learn a lot and maybe be of some help to the team and patients while we're here.  I'll post another update with  work pictures when I can.

That's all for now, thanks for reading!

Rafiki!

Well we've survived our first couple days at KCMC.  It has been quite an adjustment, as the diseases, medicines and hospital set-up are very different from what we are used to in Dallas.  Rounds and charting are all in English, although we've noticed that the Tanzanians switch easily back and forth between Swahili and English and it can be a bit tricky to follow.  I wish I spoke more Swahili so I could talk to the patients and their families more.

The pediatrics department is a referral center for this area of northern Tanzania, so they see some of the more complicated cases from the smaller area hospitals as well as taking care of the local people.  We've seen more pneumonia than I would have expected, along with some very severe malnutrition, new diagnoses of HIV, and malaria.  And I've now seen more cases of rheumatic heart disease in the last 2 days than in all my previous years of medical training in the United States.

We're hoping to get more involved on the wards teams in the next couple of days.  There are a lot of international students and a few other residents here so I think the KCMC residents are used to seeing people come and go, and wait for people to really show they are interested before they let you get too involved.  But today was better than yesterday so I have high hopes that trend will continue.

In other news, we've been adopted into the group of rotating students that was already here and have dinner plans again tonight, at a place called El Rancho that serves Indian food.  This weekend we're taking a 2 day trek to the first huts of Kilimanjaro (Marangu route) so we're hoping for good weather and good views. We've been warned it will be cold, which at this point sounds amazing.

Also, on a clear day we can see Kili from our living room window, so that's pretty cool.

We've learned a few new words in Swahili, although some of my favorite discoveries were Lion King related.

Simba = lion

Pumba = warthog

Rafiki = friend.

I also know how to say "what is your name?", "my name is Rachel," and "I am hot/cold/hungry/thirsty."  Can't wait to be able to say "I am cold" this weekend.

Now I just need to learn more useful things for the actual clinical work, turns out "lion" and "pumba" don't come up a lot at the hospital!

I need to take a picture of the hospital for my next post, but for now that's all.  Thanks for reading!

Karibu to KCMC!

We have arrived (and even unpacked) in the doctor's compound at KCMC.  Today was a pretty easy day of paperwork and orientation to the hospital, leaving us the afternoon free to run erands and get things done in town.  

Here's our home sweet home for the next 3.5 weeks:

It is much more homely and significantly cleaner after the arrival of Mary, our "house mom" this morning.

And at last, our first view of Kili when the clouds cleared for a bit.  Can't believe we are so close!

Here's a view from one of the upper floors of the medical school building.  Fun unexpected fact we learned after arriving: the dress code for women is skirts or dresses only, no trousers allowed.  Since this is the only place on the compound with internet, we may be investing in some more skirts today.

Thanks for reading!  I'll try to post again soon when we actually get to work.

Serengeti

Pictures and words just don't do this place justice, but thought I should write a quick note.

We finished our safari yesterday, and drove across northern Tanzania to Moshi, our home for the next few weeks.  The safari was amazing.  We awoke to a beautiful sunrise in the Ndutu region of the Ngorongoro Conservation area, close to the southern Serengeti.  We saw zebras in the forest during breakfast and a herd of giraffes as we pulled away from the camp.  In spite of the tents and the warnings about not setting foot outside under any circumstances, we slept reasonably well.  Our guide heard a leopard overnight but all I heard was thunder and rain.  Of course the only day we had significant rain was our one camping night!

While making our way away from the lake we happened upon a big herd of wildebeest, zebra, and a dozen elephants.  A great start to the day, and some of my favorite photos from the trip.  We were in a pretty remote area and the only safari jeep there.

We continued on the the Serengeti, with nothing but antelope for miles.  Since we had exactly 24 hours to spend in the park, our driver was on a mission to take us to the most famous and best places in the southern and central part of the park.  We saw lots of kopji, rock outcroppings with trees which are the only change in the landscape for miles.  They are also a favorite resting place of lions, and we saw at least a dozen.

We stopped at the visitor center and had lunch, and then headed off to the south in search of the migration herds.  This time of year a million wildebeest and thousands of zebra migrate from the south through the Serengeti and to Kenya, following the long rains that begin now.  All of the drivers claimed no one had been able to find the herds that day, but Stephen had a hunch.  And his hunch paid off, we found thousands of animals in a remote area of the southern plains.  What we thought was  a small herd as we approached a very slight hill was in fact a herd that stretched for miles in every direction.  The herd is mostly male wildebeest, as the calves and mothers trail along behind the herd.  Not very family oriented, these wildebeest.  Plenty of zebras as well.  The pictures don't even come close to describing it, but picture this as far as you can see in every direction.  It was incredible.

A few other favorite moments from the park: we happened upon a herd of 30 elephants, some of which were playing in the mud after a short rain.  

And on our way out we found 2 mother lions with 5 total cubs relaxing on a rock.

If you are ever in the market for a Tanzanian safari, we could not more highly recommend Naipenda Safaris and our wonderful driver Stephen.   We miss having him around as our protector and guide.

I could talk about the Serengeti for days, but you would get bored and I would not accomplish today's other tasks, namely checking out of our lovely hotel, acquiring some groceries, and moving our stuff to KCMC, our home for the next month.  

Hope you all are well!  Thanks for reading!

For more pictures, here's a link to my Flickr set:

http://www.flickr.com/photos/55870995@N08/sets/72157642080255825